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<meta name="description" content="2018年9月21日在昆明举行的，去听了一天的课，记录一下。先是李大旭老师讲上颌窦内提。我目前还不做种植，当然更不做内提喽。不过我觉得一天的课听下来收获最大的就是李老师的课了，主要是他的理念：标准化，强逻辑，每步都有逻辑，术法是次要的。本质逻辑:搞清楚上颌窦。上颌窦是啥？就是一层粘膜+骨骼，粘膜和骨之间是纤维连接，类似于牙根与牙槽骨之间的牙周膜。而我们的解剖往往不讲这个连接。粘膜对着窦腔的那面叫体">
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<meta property="og:description" content="2018年9月21日在昆明举行的，去听了一天的课，记录一下。先是李大旭老师讲上颌窦内提。我目前还不做种植，当然更不做内提喽。不过我觉得一天的课听下来收获最大的就是李老师的课了，主要是他的理念：标准化，强逻辑，每步都有逻辑，术法是次要的。本质逻辑:搞清楚上颌窦。上颌窦是啥？就是一层粘膜+骨骼，粘膜和骨之间是纤维连接，类似于牙根与牙槽骨之间的牙周膜。而我们的解剖往往不讲这个连接。粘膜对着窦腔的那面叫体">
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          <h1 class="post-title" itemprop="name headline">2018年卡瓦口腔三维影像论坛昆明站学习记录</h1>
        

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        <p>2018年9月21日在昆明举行的，去听了一天的课，记录一下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/01.jpg"><br>先是李大旭老师讲上颌窦内提。我目前还不做种植，当然更不做内提喽。不过我觉得一天的课听下来收获最大的就是李老师的课了，主要是他的理念：标准化，强逻辑，每步都有逻辑，术法是次要的。本质逻辑:搞清楚上颌窦。<br>上颌窦是啥？就是一层粘膜+骨骼，粘膜和骨之间是纤维连接，类似于牙根与牙槽骨之间的牙周膜。而我们的解剖往往不讲这个连接。粘膜对着窦腔的那面叫体外，所有成骨要在体内完成，如果膜被突破了，就谈不上成骨了。所以不管内提外提，本质是在骨与膜之间制造一定的空间来让骨在其间形成，这就要打破膜与骨之间的纤维连接。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/02.jpg"><br>外提的本质，就是用器械将膜从骨伤剥离，类似与拔牙的时候翻瓣，这就是器械要贴着骨面的原因。问题是，器械是钢制的，有一定的体积，对小结构的操作较困难。容易破。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/03.jpg"><br>而内提的原理与外提不同，构建通道后，放入骨粉，没有直接作用于骨和膜的连接，是靠撕来使其分离，而不是剥。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/04.jpg"><br>而传统内提的summers法要求剩余骨量不能少于5mm，否则只能做外提。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/05.jpg"><br>这个5mm是怎么来的呢？术式发明后经过实践发现窦底骨量能稳定提高4mm左右，而种植总共需要8mm以上的骨量，因此剩余的骨量必须大于5mm。<br>传统内提的问题:①没有止动。②上颌窦底不是平坦的。边缘有骨刺，提升越高，越容易破。<br>内提术式的本质<br>①上颌窦膜本身强度<br>②骨与膜连接的强度<br>③施力方式。<br>可控的只有③。要成功内提，施力强度大于纤维连接强度而小于窦膜强度。<br>如果大于窦膜强度，膜就先裂了。因此内提不能完全取代外提。<br>成功条件:窦膜不破损。<br>决定因素:压强。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/06.jpg"><br>根据这些逻辑，李医生发明了“膜控法”，90%以上的病例做内提，内提失败膜破了再做外提，而且剩余骨量的要求减少到了1mm。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/07.jpg"><br>具体方法和病例，我没做过内提，就不赘述了。关键是李医生这个方法：先搞清楚逻辑，再来考虑具体方法，我觉得对我启发很大。学其它临床技术也可以用这样的方法。比如龋病治疗的逻辑是什么？我个人认为：第一是消除感染，防止龋病继续发展；第二是保护牙髓；第三是恢复牙齿功能和美观。由此再进一步找到具体的做法。<br>下午武大程勇老师讲颞下颌关节病的影像学诊断<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/08.jpg"><br>cbct只能诊断骨质结构病变，看不到关节盘。磁共振/造影看关节盘。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/09.jpg"><br>目前临床主要使用全景片，颞下颌关节造影，cbct和MRI。<br>全景平上是矢状位的图像。<br>筛选病变，初步判断。<br>看下颌管的情况，只能看到一部分。<br>许勒氏片，只能显示关节外1/3病变，中，内1/3看不到。<br>重点看髁突前斜面，顶端。<br>也淘汰了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/10.jpg"><br>关节造影，小机构用得不多。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/11.jpg"><br>cbct是首选方法<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/12.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/13.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/14.jpg"><br>髁突骨质情况<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/15.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/16.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/17.jpg"><br>下面是一些病例了。<br>前牙开合，要求正畸<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/18.jpg"><br>造影显示关节盘穿孔<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/19.jpg"><br>修复患者，固定修复后一侧头部颈部疼痛。<br>右侧髁突骨质破坏。造影关节盘穿孔。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/20.jpg"><br>髁突肥大<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/21.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/22.jpg"><br>做核素显像，显示左侧髁突还在生长，暂不正畸。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/23.jpg"><br>髁突骨折<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/24.jpg"><br>关节窝破坏<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/25.jpg"><br>滑膜软骨瘤病<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/26.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/27.jpg"><br>MRI<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/28.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/29.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/30.jpg"><br>看MRI跟看X片图像不一样：髁突骨髓高密度，骨皮质低密度。所以髁突那里高密度的是骨髓，周围一圈低密度影像才是骨皮质。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/31.jpg"><br>检查方法的选择：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/32.jpg"><br>检查方法，第一类，临床检查，其余，cbct+磁共振/造影。基础是病史临床检查。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/33.jpg"><br>厂商做了一些广告，最后是南京大学王铁梅老师讲CBCT的应用。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/34.jpg"><br>表面重建，好像是她研究生的课题，一般做不到这么清晰吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/35.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/36.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/37.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/38.jpg"><br>在种植中的应用<br>全景的“坑”<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/39.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/40.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/41.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/42.jpg"><br>主要缺点，3D结构2D化<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/43.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/44.jpg"><br>王老师编的规培的教材，以 PBL,CBL病例式编写模式编写。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/45.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/46.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/47.jpg"><br>还有一个被挡住了，刀刃型。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/48.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/49.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/50.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/51.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/52.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/53.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/54.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/55.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/56.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/57.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/58.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/59.jpg"><br>口腔颌面部影像，要两侧对称看<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/60.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/61.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/62.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/63.jpg"><br>主要看骨高度 骨厚度 骨密度。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/64.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/65.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/66.jpg"><br>牙槽骨唇向移位了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/67.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/68.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/69.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/70.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/71.jpg"><br>神经管可能分叉<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/72.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/73.jpg"><br>种植术后感染<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/74.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/75.jpg"><br>术后复查，碰到神经管了？<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/76.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/77.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/78.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/79.jpg"><br>cbct在正畸中的应用<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/80.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/81.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/82.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/83.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/84.jpg"><br>颌面外科<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/85.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/86.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/87.jpg"><br>同病异影，异影同病<br>牙体牙髓牙周<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/88.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/89.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/90.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/91.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/92.jpg"><br>mb2漏了<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/93.jpg"><br>还有mb3漏了的<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/94.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/95.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/96.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/97.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/98.jpg"><br>最后是总结<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0033-kwkqyxltkm/99.jpg"></p>
<p>六点结束，回家。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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